HBA 531 - THE BODY Final Examination - December 19, 2012 · HBA 531 - THE BODY Final Examination - December 19, 2012 Name: _____ 1. Wanting to show off his new sports car, a man picks

HBA 531 - THE BODYFinal Examination - December 19, 2012

Name: _______________________________________

1. Wanting to show off his new sports car, a man picks up his brother to take him for a ride. Neither bothers to wear aseat belt. They are involved in a head-on collision in which the brother’s left lower leg is shoved against the dashboard. What soft tissue structure(s) at this knee is(are) likely to have been injured? (1.5)

Describe a test that his physician could perform do determine if such an injury had occurred:

2. Where would you feel for a pulse in the dorsalis pedis artery? (0.75)

The dorsalis pedis artery is most commonly a branch of what other artery?

3. What nerve innervates gluteus medius and minimus? (2.5)

What is the action of these two muscles at the hip?

What role do they play during human walking?

Describe the gait of a person who has suffered damage to the above named nerve on the left side.

4. After recovering from surgery for uterine cancer that included dissection of lymph nodes within the pelvis, a womanfinds she can no longer drive her car because she finds it difficult to move her foot from the gas pedal to the brakepedal. Explain in anatomical terms the most likely reason she is experiencing this difficulty: (1)

5. What nerve innervates the triceps surae (gastrocnemius and soleus)? (2.5)

When are these muscles active during a step cycle of walking, and what role are they playing?

How might a patient who had suffered paralysis to the triceps surae compensate for their loss during walking?

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The Body - Final Exam - December 19, 2012 Name: _______________________________________

6. In order to remove a pelvic tumor the surgeon finds it necessary to retract the patient’s right psoas major for aprolonged period of time. Following the surgery, the patient reports numbness over the front of his right thigh. Whatis the likely cause of this numbness? (2)

After recovering from the surgery the numbness persists and the patient initially has some difficulty walking and canonly take one step at a time on a stairway. Paralysis of what muscle(s) account(s) for these difficulties?

After a few weeks the patient finds it is no longer difficult to walk, although he still has to take one step at a time on astairway. Will there be anything unusual about this individual’s gait?

If so, describe his gait. If not, leave blank.

7. A high school quarterback is injured when he is surprised by a tackle around his knees that forces his left lower leg intoabduction. What two soft tissue structure at this knee are the most likely to have been injured? (1)

8. Standard treatment of a femoral neck fracture in a young person is by screws and/or plates. Explain with reference toanatomy why this often fails and it becomes necessary to perform a hip replacement. (0.5)

9. Match the following list of ligaments with the motions that they are designed to help limit or restrict (there may bemore than one correct answer, and answers can be used more than once): (2.25)

_____ plantar aponeurosis A. adduction of the lower leg at the knee_____ long plantar ligament B. rotation of the lower leg at the knee_____ anterior cruciate ligament C. hyperextension of the lower leg at the knee_____ lateral collateral ligament of the knee D. hyperflexion of the lower leg at the knee_____ iliofemoral ligament E. adduction of the foot at the ankle_____ deltoid ligament F. abduction of the foot at the ankle _____ plantar calcaneonavicular (spring) G. hyperflexion of the thigh at the hip

ligament H. hyperextension of the thigh at the hipI. fallen archesJ. hyperflexion of the lateral four toes at their MTP joints

10. When inserting a catheter into the common femoral artery, why is it critical that the initial needle puncture is notdirectly too obliquely upward? (1)

11. Name all of the muscles in the thigh innervated by the tibial nerve and state each of their actions. (2)

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12. Is this CT scan of a right or a left knee? (1.5)

How can you tell?

Explain with reference to human lower limb anatomy why the asymmetry you identified above exists:

13. An angiogram of a patient’s lower limb reveals a large accumulation of plaque within the portion of the superficialfemoral artery passing through the subsartorial canal. Trace out a potential anastomotic route of blood flow bypassingsuch an obstruction beginning at the external iliac artery: (2.5)

If this alternative route of blood flow is insufficient to replace the normal blood supply, what anatomic structure canbe used to surgically bypass this obstruction without major change in its location?

What must be done to this structure to make this surgical bypass successful?

14. If a segment of nerve is needed to supply a bridging segment in an attempt a repair of a different damaged nerve, whatlower limb nerve is commonly harvested for this purpose? (1.5)

Where in the lower extremity does the surgeon look for this nerve?

What other anatomic structure is very near the nerve indicating that the surgeon is on the right track in finding thenerve?

15. What muscles are located in the anterior tibial compartment? (2.5)

What nerve supplies these muscles?

What sensory test could you perform to determine whether this nerve has been damaged?

What motor test could you perform to determine whether this nerve has been damaged?

What vessel supplies the anterior tibial compartment?

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16. What muscle(s) attaches to the following bony elements? (3)

(a) ventral surface of the scapular blade (d) greater tubercle of the humerus

(b) radial tuberosity (e) deltoid tuberosity

(c) olecranon process (f) ventral surface of distal phalanx of the thumb

17. Label the indicated parts of the brachial plexus: (4.25)

18. What is meant by the term “shoulder separation”? (1)

What anatomical structures are most important in preventing this undesirable event?

19. For each of the following, name the nerve and artery related to the indicated structure or space: (1.5)

(a) the quadrangular space

(b) Guyon’s canal

(c) the medical epicondyle of the humerus

20. For the following symptoms or signs, name the nerve and muscle(s) that are most likely to be associated with thefollowing deficits: (2)

(a) marked weakness of flexion of the forearm at the elbow

(b) inability to extend the fingers at their MCP joints

21. Where would you apply a standard pin-prick sensory test to assess the function of the following nerves: (1.5)

(a) superficial radial

(b) median

(c) ulnar

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22. A woman has injured her ulnar nerve at her right wrist. Without asking her to do anything with her hand, list twoobservable characteristics of her right hand that are related to this injury. (3.25)

You then ask the woman to extend the fingers of her right hand. Describe how you expect her hand to look.

You are surprised to see all four fingers are evenly extended. What is the most likely reason why her hand does notdisplay this appearance you expected?

She does display Wartenberg’s sign, another indication of ulnar nerve damage. Describe the sign and why it occurs:

23. Place an "X" by those items in the following list that lie within the carpal tunnel: (1)

(a) ______ fibrous digital flexor sheaths (f) ______ superficial radial nerve(b) ______ tendon of palmaris longus (g) ______ ulnar nerve(c) ______ tendons of flexor digitorum superficialis (h) ______ median nerve(d) ______ tendons of flexor digitorum profundus (i) ______ radial artery(e) ______ tendon of flexor pollicis longus (j) ______ ulnar artery

24. A carpenter accidently puts his hand through a window and suffers several lacerations on the palm of his hand. Whatstructure is the emergency room physician mainly concerned about when he examines the carpenter's hand? (1)

25. Why should you always feel for a pulse prior to performing an injection into the medial cubital vein? Whatpotentially serious injury could result from failing to do so? (1)

26. Why is a deep infection of the little finger more likely to spread proximally into the carpal tunnel that one in the ringfinger? (1)

27. The man in the photograph below has suffered a nerve injury. He was asked to make a tight “O” with his thumbs andindex fingers. (1.5)

Is the injury on the right or left side?

What nerve has been damaged?

Explain your diagnosis.

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28. The man in the image below has been asked to lean against the wall on his hands. (0.75)

What is the name of the symptom he displays?

Name the nerve that has been damaged and the muscle that hasbeen paralyzed:

If after lowering his arms he abducted his right arm at the shoulder,would his condition likely get better or worse?

29. Below are a series of T1 weighted MR images of a woman’s distal forearm, the first being the most proximal and thefourth the most distal. Structures appearing in multiple images are identified only once. Identify the labeled structures:(2.25)

A __________________________________ F __________________________________

B __________________________________ G __________________________________

C __________________________________ H __________________________________

D __________________________________ I ___________________________________

E __________________________________

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30. On the right is a lettered list of different functional types of neurons. On the left is a list of structures. In the blankfollowing each named structure, enter the letters of the types of axons within it. For any given blank, your list must beentirely correct to generate any credit. (1.75)

(a) gray ramus communicans of C2 ______________________ A - somatic motor(b) white ramus communicans of L1 _____________________ B - somatic sensory(c) the posterior vagal trunk _______________________ C - visceral sensory(d) the pelvic splanchnic n. from S3 ______________________ D - preganglionic sympathetic(e) the musculocutaneous n. _______________________ E - postganglionic sympathetic(f) the intercostobrachial n. ______________________ F - preganglionic parasympathetic(g) the greater occipital n.___________________ G - postganglionic parasympathetic

31. How does damage to the inferior hypogastric plexus differ from damage to the pelvic plexus in terms of its effect onmale reproductive function? (1)

32. A 54 year old woman presents with a palpable mass in her breast and a dimple on the overlying skin. What is the mostlikely cause of the dimple? (2.5)

Along what blood vessels are the level 1 nodes located and what percent of breast lymph drains to these nodes?

To which nodes does the remainder of the breast lymph drain?

33. While picking up debris from in his yard, N. K. feels a snap in his back. Two days later he experiences pain on thelateral surface of his lower leg, dorsum of his foot, and along the foot’s medial border. (1.5)

In N. K.’s case, you deduce that the __________ nerve has been affected by disease of the _________ disc.

Describe a motor test that, if performed weakly, would verify your suspicion?

34. Why might dilatation of the pulmonary trunk secondary to pulmonary hypertension lead to hoarseness? (0.5)

35. As a student on your medicine clerkship, the attending physician asks you to assess the size of the prostate gland.How and where do you feel it? (0.5)

36. Both colon and rectal cancers may metastasize to the liver and/or the lung. Why is the presence of metastases in thelung without any in the liver more common in the case of rectal cancer than colon cancer? (1)

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37. On the right is a lettered list of heart structures. On the left is a list of arteries. In the blanks following each namedartery, enter the letters associated with the heart structures it supplies. For any given blank, your list must be entirelycorrect to generate any credit. (2.75)

IN A RIGHT CORONARY IN A LEFT CORONARYDOMINANT HEART DOMINANT HEART

right coronary a. _________________ __________________ A - right atriumcircumflex coronary a. _________________ __________________ B - right ventricleLAD (ant. interventric. a.) _________________ __________________ C - left atriumPDA (post. interventric. a. _________________ __________________ D - left ventricle(acute) marginal a. _________________ __________________ E - SA nodeobtuse marginal aa. _________________ __________________ F - AV nodediagonal aa. _________________ __________________

38. Describe the surface anatomy of the following (2.5)

(a) the apex of the right lung -

(b) the left brachiocephalic vein -

(c) the best site to hear the aortic valve-

(d) the aortic bifurcation -

(e) the superficial inguinal ring -

39. Provide an anatomical explanation for the following: (5)

(a) cancer of the head of the pancreas reveals itself by painless jaundice, whereas cancer of the tail does not

(b) a lumbar puncture should be performed above or below the vertebral spine that lies on the supracristal plane

(c) an anesthesiologist specially trained to monitor spinal cord function is invaluable during an operation to repair ananeurysm of the aorta just distal to the left subclavian artery

(d) cirrhosis of the liver may cause death by hemorrhage

(e) cutaneous sensation from the belly button down to the mons pubis is assessed during an attempt to perform epidural anesthesia to diminish the pain of the first stage of labor

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40. A blow to the temple may fracture the thin bone on the lateral side of the braincase. What is the name of the vesselthat is most likely to be injured by a fragment of bone? (2)

What is the name given to the condition likely to arise from injury to this vessel?

It is generally considered that this condition is of greater urgency than that arising when a blow to the front of thehead produces intracranial bleeding. Why?

41. Explain why contraction of the ciliary muscle does not enable a near-sighted (myopic) person to focus on distantobjects. (0.5)

42. What things can you do to a patient, or ask her to do, to test the function of the sphincter pupillae? (1)

43. Below is depicted a superior view of the two eyeballs. Shade or crosshatch the intact visual field of a person whoseoptic chiasm is severely injured. (1.5)

Tumor of what structure is most likely to cause optic chiasm compression? ____________________________

44. What is the greatest risk to health of a patient with Bell’s palsy, and why does it arise? (1)

45. Bell’s palsy is usually associated with symptoms that arise during chewing. Identify two such symptoms and statewhy they arise. (2)

46. Provide an anatomic explanation for why infants with uncorrected clefts of the soft palate are more likely to havemiddle ear infections? (1)

Why does this tendency tend to disappear as the child gets older?

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47. Describe the best test to determine if the masticatory muscles of one side are weaker than those of the other side. Whatwould be the result if the muscles on the right side were the weaker? (2)

48. From what larger nerve does the right recurrent laryngeal nerve branch off? __________________________ (3.5)

Around what structure does it recur? _________________________________

Describe its path in terms of its relationships beyond this site up to the level of the cricoid cartilage and at the level ofthe cricoid lamina.

What laryngeal muscle(s) on the right side will still function if it is damaged?

What will be the initial position of the right vocal fold after a right recurrent laryngeal nerve injury?

How will this injury affect one’s daily activities and explain why these effects occur.

49. What is the name of the first lymph nodes to receive lymph from the tip of the tongue? (.5)

50. Paralysis of which muscles leads to the following symptoms, and which cranial nerves (or in the case of thetrigeminal, which divisions) innervate them? (Do not name specific branches of nerves.) In all cases state the side ofthe paralysis, and give name and number of the cranial nerve. (3)

Muscle Cranial Nerve(a) sounds seem painfully loud in your right ear _______________________ ___________________(b) when you turn your head to face toward the left,

an examiner can easily push it back to facing forward _______________________ ___________________

(c) you cannot shrug your left shoulder _______________________ ___________________(d) your tongue seems to deviate to the right

when you try to stick it out of your mouth _______________________ ___________________

(e) your uvula shifts to the left when you say “Aaah” _______________________ ___________________(f) your right eye points medially

and cannot be brought to point straight ahead _______________________ ___________________

51. Name one structure that passes through each of the following openings in the skull. (2)

(a) foramen spinosum ____________________________________(b) foramen ovale ____________________________________(c) mandibular foramen ____________________________________(d) stylomastoid foramen ____________________________________

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52. A year after surgery to remove a benign tumor of the right parotid gland, a patient complains of unusual sweating ofthe skin over the right side of his face whenever he eats. Explain this phenomenon. (.5)

53. In older people the footplate of the stapes may become fixed to the bone surrounding the oval window. This conditionis called otosclerosis. It produces a significant hearing loss. So would a tumor of CN VIII. Name and describe themost reliable test you could use that might distinguish between a hearing loss due to otosclerosis and one due to atumor of CN VIII. State the result of this test in the case of otosclerosis. (1.5)

54. Using the code indicated on the right, indicate all the functions served by cells in the ganglia listed on the left. Forany given blank, your list must be entirely correct to generate any credit. (1.75)

geniculate ______________________ A = general sensorysubmandibular ______________________ B = tastetrigeminal _______________________ C = hearing/balanceciliary _______________________ D = somatic motorpterygopalatine ________________________ E = parasympatheticotic _______________________ F = sympatheticstellate________________________ G = none of the above

55. State the surface anatomy of the following (3)(a) parotid duct -

(b) the site where the accessory nerve enters the posterior triangle -

(c) where you would inject anesthetic in order to anesthetize most of the skin of the right forehead -

(d) isthmus of thyroid gland -

(e) site where you should perform emergency entrance into the airway in a choking person -

(f) the site of the external carotid artery pulse -

56. Billy normally holds his head as shown in figure A. In picture Bit is being “forced” into a different position. (1.5)(a) What is (are) paralyzed and what innervates it (them)?

(b) What about picture B gave you a clue to the problem(s) andwhat accounts for this(these) clues?

(c) Why does he normally hold his head as in picture A?

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57. To the right are images of twodifferent patients: (a) and (b). In eachcase identify the nerve(s) thathas(have) been injured. Be sure to statethe side of injury. Then give at least two reasons for each of your answers.(3)

(a) injured nerve(s) ______________________________________________________________reasons:

(b) injured nerve(s) ______________________________________________________________reasons:

58. Label this axial CT. (2.25)

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HBA 531 - THE BODY Final Examination - December 19, 2012 · HBA 531 - THE BODY Final Examination - December 19, 2012 Name: _____ 1. Wanting to show off his new sports car, a man picks